can I please get help with finding codes for these cases

OPSX29GradyKent

MCCG240 Case Scenario OPSX29 Grady, Kent.html[10/21/2021 10:55:46 AM]

Outpatient Surgery

Patient Case Number: OPSX29-Grady, Kent

Patient Name: Kent Grady DOB: 07-13-70 Sex: M

Date of Service: 01-22-XX Surgeon: Mary Hollister, MD

Pre-Operative Diagnosis Acute Pancreatitis

Post-Operative Diagnosis Esophageal Varices

Procedure Performed: EGD & Endoscopic ultrasound

Anesthesia: Conscious sedation Complications: None

PROCEDURES: 1. EGD 2. Endoscopic ultrasound.

INDICATIONS: 1. Acute pancreatitis. 2. Abnormal CT scan, rule out pancreas head mass.

PROCEDURE #1 EGD: The Olympus GIF-190 forward-viewing video-endoscope was lubricated and advanced into the hypopharynx. The scope passed into the esophagus. Examination of the stomach was performed in straight and retroflexion views. The scope was passed into the second portion of the duodenum.

FINDINGS: 1. Grade 1 esophageal varices x1. 2. Food debris in the proximal stomach, otherwise, normal stomach. 3. Normal duodenum. 4. Acute and chronic pancreatitis

PROCEDURE #2 ENDOSCOPIC ULTRASOUND: The Olympus linear echoendoscope was lubricated and advanced into the hypopharynx. The scope passed through the esophagus, stomach, pylorus second portion duodenum. With the water-filling technique of the balloon and lumen, endoscopic ultrasound examination performed. The pancreas parenchyma appeared with diffuse inhomogeneity, hypoechoic foci, lobulation, and a few calcifications in the head of the pancreas. The main pancreatic duct was not dilated, and it had thickened borders. Folds features are suggestive of chronic pancreatitis. The common bile duct was dilated measuring 9 mm. There was free fluid around the pancreas body and tail. The splenic vein was distended, consistent with portal hypertension.

OPSX29GradyKent

MCCG240 Case Scenario OPSX29 Grady, Kent.html[10/21/2021 10:55:46 AM]

RECOMMENDATIONS: 1. Alcohol abstinence. 2. Repeat EUS in 3 months.

Dictating Clinician: Mary Hollister, MD

Electronical Signed By: Mary Hollister, MD

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